Feature, Report

Hygiene reigns supreme in return to practice

The days of casually leaning on the reception desk at medical clinics are gone, replaced instead with plastic screens, hand sanitiser and non-contact thermometers. Insight takes a snapshot of the return-to-work landscape as the sector emerges from COVID-19.

Eyecare professionals only need to cast their minds to the origin of the COVID-19 crisis as a reminder of the risks they now face in their line of work.

Dr Li Wenliang, a Wuhan ophthalmologist who helped blow the whistle on the emergency, was among the first of many global healthcare workers to die from the disease after contracting it from a glaucoma patient.

Since then, several studies have demonstrated a connection between coronavirus and its potential to transmit and replicate in the eyes. Because of their physical proximity to patients, ophthalmic professionals have also been identified as one of the most at-risk occupations for virus exposure.

In the face of such evidence, Australian eyecare providers and health authorities have enforced strict practice hygiene and protective measures that many predict will be in place for months, or even permanently.

It has all come at a great cost too. Restrictions on patient volumes has impacted the revenue line for many practices and clinics. This is in addition to the lay-off during forced shutdown, and the added expense of additional personal protection equipment (PPE) and breath shields and barriers – some of which is purpose-made or even sourced from Bunnings.

Alongside practice hygiene guidelines, the government-led directive on surgery volume governing how many patients can go under the knife is also affecting through-put and feeding concerns about an eminent backlog.

Insight speaks to three ophthalmologists about how they are managing a safe return to work.

A surreal situation

Sydney-based ophthalmologist Tim Roberts is Clinical Associate Professor at The University of Sydney and medical director of Vision Eye Institute (VEI), the largest private provider of ophthalmic care in Australia with 27 locations across the country.

He is also a consultant at Royal North Shore Hospital, a major public teaching hospital in Sydney with COVID-19 dedicated facilities.

From the beginning of the coronavirus outbreak, Roberts has met weekly via video-conferencing (but more frequently during the height of the pandemic) with CEO and managing director James Thiedeman, and VEI’s Medical Advisory Board, to steer VEI through the pandemic.

Sydney-based ophthalmologist and medical director of Vision Eye Institute Tim Roberts.

Roberts says the policy for his group has been to adhere to the National Cabinet and Federal Government’s Department of Health guidelines, and follow the advice of the Australian Government Chief Medical Officer throughout the initial disruptions and subsequent tightening restrictions on healthcare.

“One of Australia’s strengths during COVID-19 has been a strong collaborative allegiance at National Cabinet,” he says.

“We’ve determined our policies based on Australia’s Chief Medical Officer’s guidelines, even though they’ve differed slightly from time-to-time from those of RANZCO and the AMA (Australian Medical Association).”

Roberts says that while there has been a significant reduction in patient numbers, their focus at VEI has been to support and maintain their staff while continuing to provide patient care.

“We have been converting our practices which has included installing splashguards on all our equipment and removing all magazines, brochures and children’s toys from our waiting rooms. Each clinic has ample supplies of hand sanitiser for staff and visitors and undertakes two-hourly cleaning of all surfaces, with consulting rooms cleaned after each patient,” he says.

“We’re also conducting a pre-screening concierge service. We question patients about their travel history and if they are displaying any symptoms of illness. We ask them to sign a disclaimer, and then they are admitted into the practice. If a patient rings and wishes to cancel their appointment, we offer a telehealth consultation, and take that opportunity to promote a public health message.”

Despite being costly and difficult to source at times, VEI has also ensured it has appropriate infection control including PPE in theatre and clinics, hand sanitiser, and face masks.

Roberts says reduced consulting numbers and ensuring social distancing measures in waiting rooms have helped keep infection risks low.

“The risk of infection is two-fold; from contact outside of 1.5 metres, which is why we have line markings on the floor for social-distancing, and from aerosolisation inside 1.5 metres, which is why we have installed splashguards on equipment including slit lamps and lasers, and limited the time staff and doctors spend close up with patients,” he says.

“We’re seeing fewer patients because we have to socially distance patients in the waiting room, including patient carers.”

Roberts says VEI’s time-in-motion studies show exactly how many patients can be safely seen in the clinic.

The pandemic has resulted in a significant economic downturn for doctors and hospitals providers.

“We’ve seen a 70% reduction in work and revenue in April. It’s starting to plateau off and our patient volumes are now improving,” he said in May.

The single largest contributor to this downturn was the Federal Government’s suspension on elective surgeries across private and public hospitals on 25 March as the health sector braced for a looming public health emergency in response to the pandemic.

“Similar to other industries, the pandemic has resulted in a significant economic downturn for doctors and hospitals providers. The cost of operating at only 25% capacity is significant, but that is the price we are willing to pay to protect our community,” he says.

The restriction on elective surgery was partially lifted on 27 April with the government announcing the first phase in a gradual loosening of elective surgery restrictions with all Category 2 procedures, and ‘important’ Category 3 surgeries, which include cataracts and eye procedures, getting the green light.

“In 30 years in ophthalmology, this is the first time we’ve gone months without operating,” Roberts explains. “Reflecting on different generations, you can’t choose the world you live in. Other generations have lived through the Depression, World Wars, and the Spanish Flu.”

He describes the ban on elective surgery in medicine and the government closure of private hospitals as “surreal” and has seen the “ripple effect” of the psychological and social impact of COVID.

“People are uneasy; they’re tentative. Anxiety is creeping in; there’s a hint of agoraphobia as the Southern Hemisphere heads into winter,” he says.

“We’ve been calling patients to say we’re open but many are declining to make an appointment in the immediate future. Elderly patients don’t want to come out; adult children with elderly parents don’t want them to come out.”

Looking ahead, Roberts predicts if there isn’t a second wave outbreak, surgery capacity should continue to return to pre-COVID levels, but if there is a second wave, there’ll be a rapid reactivation of restrictions to preserve PPE.

He also knows there will be a patient backlog, particularly in the public health system, which he has seen first-hand at Royal North Shore Hospital.

“Public hospitals will need to re-think how to categorise cases and schedule surgery and appointments, as outpatient and elective surgery waiting lists have understandably blown out,” he notes.

“The volume of patient loads is different between the private and public system. The private system can expand capacity, but the public system has limited capacity, and budget, to expand,” Roberts says.

“I’m concerned for patients on public waiting lists, particularly cataract surgery patients, as performing cataract surgery and improving vision has significant social and public health value.”

Hygiene protocol variable 

Heather Mack is president of RANZCO and Clinical Associate Professor of Ophthalmology at the University of Melbourne. She practices in Doncaster, East Melbourne, and Malvern.

She notes that consulting and surgery volumes are down for a number of reasons, but having fewer patients makes it easier to manage practice hygiene without the pressure of high volumes of patients and their carers coming through the clinic.

RANZCO president and ophthalmologist Heather Mack.

“Day surgeries and centres put in place their own practice hygiene guidelines, guided by Federal Government guidelines, and local state, hospital or agency guidelines, such as Safer Care Victoria, the peak Victorian authority for quality and safety improvement in healthcare.”

Mack says practice hygiene protocol varies from place to place: “Cabrini Health in Melbourne is screening patients, visitors and staff with a verbal questionnaire, infra-red temperature check, and hand sanitiser before entering the hospital. In my practice, we’re screening patients with a questionnaire by phone before arrival, and instructing carers and drivers to wait elsewhere, such as in their car.

“Patients are required to sanitise their hands when they arrive, and we run through a series of questions about health and travel again. We allow a minimum number of people in the practice and we’ve installed Perspex screens – they will remain in place indefinitely.”

When the government announced it was easing surgery restrictions, RANZCO released its own Return to elective surgery guide, cautioning that operating lists and through-put would be restricted by social distancing and infective precautions. It offered advice on how ophthalmologists should handle asymptomatic patients with no known symptoms, as well as confirmed or suspected cases.

“We’re limiting patient examinations to less than 15 minutes wherever possible – some ophthalmologists are taking patient history over the phone rather than in person,” Mack says.

“We limit what we do; we’re not doing lacrimal syringing because of the high risk of aerosolisation. We’re taking precautions, our equipment is regularly cleaned, we’ve installed breath shields on slit lamps. Wearing masks is variable – it depends on jurisdiction.”

Advertising the availability of ophthalmology clinic services also comes with inherent challenges. Regulated health services must comply with stringent advertising criteria stipulated by Medical Board of Australia guidelines, under the Australian Health Practitioner Regulation Agency umbrella.

As such, ophthalmologists are notifying patients that they are ‘open for business’ the old-fashioned way, by phoning patients individually.

“There is a big risk of patients not attending for care,” Mack says, which is why community service announcements such as those by the Macular Disease Foundation Australia and patron Ita Buttrose about intravitreal injections appointments are supported across the board, including by RANZCO.

Like Dr Roberts, Mack predicts there will be a backlog of patients requiring eye procedures as restrictions on capacity continue to lift.

“When it’s possible to resume normal care, there’ll be a backlog of patients with visual loss. This is already happening with some immunosuppressed uveitis patients. It’s possible we’ll see more patients presenting with serious ocular pathology because they haven’t received treatment for four to six weeks, during the forced shutdown.”

Capacity confusion 

Associate Professor Adrian Fung is a retinal surgeon who works at multiple sites in Sydney including Westmead Hospital, Macquarie University Hospital, and private practice in Miranda, Hurstville, Chatswood, Bondi Junction and Liverpool.

He is a co-author of the RANZCO COVID-19 guidelines and is vice- chair of the college’s Clinical Standards Committee. He was guest speaker at a recent international webinar on practice hygiene and how to mitigate risk for patients in-clinic, particularly macular disease patients.

Sydney retinal surgeon Adrian Fung.

“I spoke about RANZCO’s triage guidelines in Australia and the importance of continuing intravitreal injections for conditions such as AMD, despite the seriousness of the pandemic,” Fung says.

Most Australian ophthalmologists follow a treat-and-extend regime and the guidelines suggested extending this to the maximum interval possible in order to minimise visits. This is similar to the
USA but contrasts to many other counties in the world who have a fixed regime or a pro re nata (PRN, or as-needed) regimen. We’re encouraging patients to see their ophthalmologist, in line with advice from the Chief Medical Officer.”

He says RANZCO’s guidelines and protocols adopted during the pandemic are in accordance with national and state Department of Health guidelines.

“We’ve tried to allow for some flexibility for the local situation. Our guidelines don’t contradict national or state guidelines, but we try to give discretion to ophthalmologists to adopt the recommendations according to the prevalence and level of risk of COVID-19 in their area,” Fung states.

“We’re conscious that COVID is a serious public health emergency but we’re also conscious of the ocular morbidity associated with not seeing patients to provide treatment in a timely manner.”

State governments have given hospitals in NSW and Victoria the green light to increase elective surgery from 25% of pre-pandemic levels – the limit imposed when the ban on most non-essential surgeries was partially lifted in late April – to 50% by May 31, then 75% by June 30.

Fung says most ophthalmologists are compliant with COVID guidelines but the 25% capacity directive from the Federal Government – in place when Fung spoke with Insight – had caused some confusion.

“There has been some difficulty in knowing how to interpret that 25% reduction. In some hospitals, surgeons had not been given clear directions on how many patients they were allowed to book. I’m aware of some surgeons who booked a number of patients on their elective operation list, only to be told by their hospital at the last minute to reduce their list,” Fung says.

More recently there have been clearer instructions depending on the volume of surgery each surgeon had historically booked.

Fung welcomes the Federal Government’s staged approach
to relaxing the rules around elective surgery but was wary that a second-wave outbreak could potentially diminish supply of PPE and put another stop-work on elective surgery.

He says precautions are heightened in a bid to avoid complacency.

“Our profession’s key message is it is important to see patients because ocular morbidity will increase if we don’t. We’ve put precautions in place, such as pre-screening patients for COVID-19 risk factors, enforcing 1.5 metre social distancing in waiting rooms, limiting accompanying persons to one, installing breath shields over slit lamps, and regularly cleaning the clinic.”

Some measures that have been introduced during the pandemic to reduce the risk of infection might be here to stay, he adds.

“Avoiding shaking hands, the removal of magazines and toys from waiting rooms, contactless payment instead of cash, and non-contact temperature checks, may all be here to stay permanently.”

Optomery warning over tonometry and visual fields 

Optometry Australia (OA) is recommending high level disinfection for reusable tonometer probes as part of its infection control advice to help optometrists return to work safely alongside their patients.

OA’s Infection control and COVID-19 factsheet, released in June, provides updated, evidence-based information for optometrists, their staff and their practices on pertinent pandemic infection control procedures.

One of the most important changes to instrument disinfection relates to contact tonometry.

It highlights that the gold standard for disinfection of semi-critical devices – a category that includes tonometer probes – requires either sodium hydrochlorite or Tristel Duo OPH, a new product which uses chlorine dioxide as the active agent, and is approved by the Therapeutic Goods Administration (TGA) for high level disinfection
of instrument grade surfaces.

Compiled by OA’s policy and standards advisors, optometrists Ms Kerryn Hart and Ms Cassandra Haines, the factsheet summarises infection control in a compact resource designed to be used in practices.

Hart says one of the most important changes to instrument disinfection relates to contact tonometry.

“What is now suggested is using high level disinfectant, like Tristel Duo, on reusable probes, which has obtained TGA approval for semi- critical medical devices, or – if not available – bleach, as our review of the literature suggests use of an alcohol swab does not provide appropriate viricidal activity,” she says.

“If tonometry cannot be deferred, a single-use disposable applanation tonometry prism, or iCare tonometer with disposable probes, is recommended.”

OA’s advice on visual field instrument disinfection notes that infection control practices suggest using an appropriate disinfectant to reduce potential surface contamination on the chin rest, forehead rest, trigger and bowl.

However, as OA’s factsheet acknowledges it may be impractical to clean the interior of the perimeter bowl without damaging the machine and the virus could remain airborne in the enclosed space for an unknown length of time.

It recommends visual field testing should be avoided if possible.

“Some hospitals and ophthalmology practices have ceased visual field testing unless urgent and our guide suggests suspected or confirmed COVID-19 patients wear masks if testing is unavoidable,” the authors note.

Infection control and COVID-19 factsheet is an open access document available on OA’s website.

Zeiss unveils disinfectant and protection programs 

Since the outbreak, Zeiss has been fielding many inquiries by Australian eyecare professionals about the best disinfection methods for its surgical microscopes, OCT devices and perimetry systems – without causing damage to key components.

It has responded with a range of comprehensive cleaning guides and has also been supplying protective equipment that can be attached to instruments to help eyecare professionals reduce the risk of COVID-19 infection.

Disinfecting the surfaces of surgical microscopes with certain solutions does not affect their performance.

The most successful of those has been its free slit lamp breath shield offer, which is also available to non-Zeiss customers. Some 3,000 breath shields have been sent across Australasia, along with 80,000 globally.

In line with advice from the US Centers for Disease Control and Prevention (CDC), Zeiss recommends disinfecting device surfaces with a disinfectant solution of at least 70% alcohol, such as isopropyl alcohol.

Based on experience, Zeiss states disinfecting the surfaces of its surgical microscopes with such solutions does not affect their performance or pose a risk to the patient/user. However, there is a chance that surfaces can become dull or matt. It is also possible that adhesive labels may become detached during long-term exposure, but won’t fall off.

For surgical microscopes, Zeiss also provides single-use drapes that can cover the microscope body and head, as well as drapes that cover the objective lens (called VisionGuard).

For its Cirrus OCT systems, the company advises lenses should be cleaned using only water, isopropyl alcohol and acetone. Up to 99% isopropyl alcohol can be used for cleaning the optical surfaces.

Cleaning of optical surfaces can be done as much as needed – such as between patients – but there will be an increased risk of damage to the optical surfaces if there are hard particles on the surface and too much pressure is applied.

For the HFA, professionals are required to take extra care due to the delicate surfaces of the perimeter’s bowl and optics.

Zeiss has detailed cleaning instructions on how to treat Humphrey perimeters and the testing room. Also included is new guidance on how to clean the bowl, which includes warnings about the potential for scratching, discolouring or staining the bowl surface. It also advises care to avoid getting distilled water or isopropyl alcohol cleaning liquid inside the fixation target openings or on mirrored surfaces.

Zeiss has also provided advice on how to set up Cirrus HD-OCT and HFA so that eyecare professionals can operate it somewhat remotely.

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